Treading lightly through therapy cap claims containing KX modifier

There are several Medicare legislative provisions that expired in 2017 that have yet to be renewed, one of them being the Medicare Part B outpatient therapy caps. To limit the effects on Medicare beneficiaries, starting January 1, 2018, CMS began holding claims affected by the expiration of the therapy caps process and containing the KX modifier. Now that claims hold is being changed to a "rolling hold" starting January 31, 2018, to reduce the number of claims requiring reprocessing if therapy caps legislation is enacted.

KX modifier. When a claim is submitted with the KX modifier, it indicates that the therapy cap has been met but the services qualifies for an exception regarding payment. By using the KX modifier, the provider attests that the services are reasonable and necessary and medical necessity is documented in the beneficiary’s medical record.

Original claims hold. Starting January 1, 2018, claims therapy claims that contained the KX modifier were held. Claims that were submitted without the KX modifier were paid if the therapy cap had not been exceeded, but denied if the cap had been exceeded. Starting January 25, 2018, therapy claims with the KX modifier with date of receipt between January 1 and January 10 were immediately released for processing.

Rolling hold. Starting January 31, 2018, CMS will release the held claims one day at a time based on the date the claim was received, on a "first-in, first-out basis." Therapy claims with the KX modifier that are newly received will be held from processing and a rolling hold of 20 days of claims will be implemented. This means that on January 31, CMS will hold all claims with the KX modifier that are received while releasing for processing the claims received on January 11; February 1 claims will be held and claims received on January 12, will be released; and so on.